Percutaneous left atrial appendage occlusion in the current practice

Abstract

Oral anticoagulation (OAC) is the standard of care for stroke prevention in atrial fibrillation, but it is associated with a substantial risk of bleeding complications and its effect depends on optimal patient ́s compliance. In patients with nonvalvular atrial fibrillation, the left atrial appendage is the source of thrombi that may cause stroke in up to 91% to 95% of cases. Thus, percutaneous left atrial appendage occlusion (LAAO) is being increasingly performed as an alternative to OAC for stroke prophylaxis in patients at increased bleeding risk. The current evidence supporting LAAO derives from 3 randomized controlled trials: 2 on Watchman device use in patients eligible for short‑term OAC and a more recent trial comparing LAAO with Amulet and Watchman device use versus long‑term OAC with direct oral anticoagulants (DOACs). In addition, numerous real‑life registries have reported favorable outcomes with Watchman, ACP, and Amulet devices in patients at higher bleeding risk and / or formal contraindications to short‑term OAC, employing less intensive antithrombotic regimens after LAAO. Furthermore, there has been growing evidence on newer devices with distinct features that might be of value to specific subgroups of patients. However, several issues remain unresolved including optimal patient and device selection, individual tailoring of postprocedural antithrombotic therapy, and management of periprocedural complications such as device‑related thrombus and residual peridevice leaks. Finally, the relative benefit of LAAO versus DOACs should be further assessed across the spectrum of patient candidacy for DOACs, over extended follow‑up periods. In this article, we review the body of evidence supporting LAAO with currently available devices.